Prescription Drug Coverage

Drugs Covered under Medicare Part B

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.

Drugs Covered under Medicare Part D

General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.aetnamedicare.com/plan_choices/rx_find_prescriptions.jsp on the web.

Different out-of-pocket costs may apply for people who

have limited incomes,

live in long term care facilities, or

have access to Indian/Tribal/Urban (Indian Health Service) providers.

The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Total yearly drug costs are the total drug costs paid by both you and a Part D plan.

The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

If you request a formulary exception for a drug and Aetna Medicare Select Plan (HMO) approves the exception, you will pay Tier 3: Non-Preferred Brand cost sharing for that drug.

In-Network

$0 deductible.

Initial Coverage

You pay the following until total yearly drug costs reach $2,850:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Generic

$10 copay for a one-month (30-day) supply of drugs in this tier

$20 copay for a two-month (60-day) supply of drugs in this tier

$30 copay for a three-month (90-day) supply of drugs in this tier

Tier 2: Preferred Brand

25% coinsurance for a one-month (30-day) supply of drugs in this tier

25% coinsurance for a two-month (60-day) supply of drugs in this tier

25% coinsurance for a three-month (90-day) supply of drugs in this tier

Tier 3: Non-Preferred Brand

50% coinsurance for a one-month (30-day) supply of drugs in this tier

50% coinsurance for a two-month (60-day) supply of drugs in this tier

50% coinsurance for a three-month (90-day) supply of drugs in this tier

Tier 4: Specialty Tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a two-month (60-day) supply of drugs in this tier

33% coinsurance for a three-month (90-day) supply of drugs in this tier

Tier 5: Select Care Drugs

$0 copay for a one-month (30-day) supply of drugs in this tier

$0 copay for a two-month (60-day) supply of drugs in this tier

$0 copay for a three-month (90-day) supply of drugs in this tier

Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s):

Tier 1: Generic

$10 copay for a one-month (31-day) supply of drugs in this tier

Tier 2: Preferred Brand

25% coinsurance for a one-month (31-day) supply of drugs in this tier

Tier 3: Non-Preferred Brand

50% coinsurance for a one-month (31-day) supply of drugs in this tier

Tier 4: Specialty Tier

33% coinsurance for a one-month (31-day) supply of drugs in this tier

Tier 5: Select Care Drugs

$0 copay for a one-month (31-day) supply of drugs in this tier

Mail Order

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s):

Tier 1: Generic

$10 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$20 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy.

$20 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$20 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Tier 2: Preferred Brand

25% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

25% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy.

25% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

25% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

25% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

25% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Tier 3: Non-Preferred Brand

50% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

50% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy.

50% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

50% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

50% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

50% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Tier 4: Specialty Tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

33% coinsurance for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy.

33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

33% coinsurance for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Tier 5: Select Care Drugs

$0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.

$0 copay for a two-month (60-day) supply of drugs in this tier from a preferred mail order pharmacy.

$0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.

$10 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$20 copay for a two-month (60-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

$30 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.

Coverage Gap

After your total yearly drug costs reach $2,850, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 72% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,550.

Additional Coverage Gap

The plan covers few formulary generics (less than 10% of formulary generic drugs) through the coverage gap.

The plan offers additional coverage in the gap for the following tiers. You pay the following:

Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 5: Select Care Drugs

$0 copay for a one-month (30-day) supply of all drugs covered within this tier

$0 copay for a two-month (60-day) supply of all drugs covered within this tier

$0 copay for a three-month (90-day) supply of all drugs covered within this tier

Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 5: Select Care Drugs

$0 copay for a one-month (31-day) supply of all drugs covered within this tier

Mail Order

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

Tier 5: Select Care Drugs

$0 copay for a one-month (30-day) supply of all drugs covered within this tier from a preferred mail order pharmacy

$0 copay for a two-month (60-day) supply of all drugs covered within this tier from a preferred mail order pharmacy

$0 copay for a three-month (90-day) supply of all drugs covered within this tier from a preferred mail order pharmacy

$10 copay for a one-month (30-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy

$20 copay for a two-month (60-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy

$30 copay for a three-month (90-day) supply of all drugs covered within this tier from a non-preferred mail order pharmacy

$2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.

Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Aetna Medicare Select Plan (HMO).

You can get out-of-network drugs the following way:

Out-of-Network Initial Coverage

You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,850:

Out-of-Network Initial Coverage

Tier 1: Generic

$10 copay for a (10-day) supply of drugs in this tier

Tier 2: Preferred Brand

25% coinsurance for a (10-day) supply of drugs in this tier

Tier 3: Non-Preferred Brand

50% coinsurance for a (10-day) supply of drugs in this tier

Tier 4: Specialty Tier

33% coinsurance for a (10-day) supply of drugs in this tier

Tier 5: Select Care Drugs

$10 copay for a (10-day) supply of drugs in this tier

Out-of-NetworkCoverage Gap

You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,550. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s).

Additional Out-of-NetworkCoverage Gap

You will be reimbursed for these drugs purchased out-of-network up to the plan's cost of the drug minus the following:

Tier 5: Select Care Drugs

$10 copay for a (10-day) supply of all drugs covered within this tier

Out-of-NetworkCatastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,550, you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, which is the greater of:

5% coinsurance, or

$2.55 copay for generic (including brand drugs treated as generic) and a $6.35 copay for all other drugs.

Inpatient Hospital Care

No limit to the number of days covered by the plan each hospital stay.

For Medicare-covered hospital stays:

Days 1 - 7: $264 copay per day

Days 8 - 90: $0 copay per day

$0 copay for additional non-Medicare-covered hospital days

Outpatient Care

Inpatient Mental Health Care

In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

Additional Benefits

Preventive Services

General

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

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